Learning Healthcare Systems and Driving Changes in Quality of Care

David Flum, MD MPH Professor Surgery, Health Services and Pharmacy

University of Washington

Strategies for Improving Surgical Quality

•E.g. NSQIP, STS

•E.g. NNE, SCOAP, MSQC

•E.g. P4P, SCIP Measures

• E.g. COE

Selective Referral

Process Compliance

Outcomes Feedback

Regional CQI and Learning

Systems

Outline

• NNE • The Tools of the Surgical Collaborative and

Learning System – Michigan – Washington

• Take home points

CQI Toolbox

Data Performance feedback Collaborative meetings Surveys, site visits, videotape

Rate Of Overall Bypass Surgery Mortality Improvement, by State

Chassin M R Health Aff 2002;21:40-51

©2002 by Project HOPE - The People-to-People Health Foundation, Inc.

The Michigan Program

• Partnership between BCBSM, Michigan hospitals, and clinician scientists

• 12 collaborative quality improvement programs Cardiac care, cancer surgery, bariatrics, breast cancer, cardiac CT,

trauma/ acute care, joint replacement, and medical admissions 50+ hospitals 200,000+ pts / year

• $30 million annual investment from BCBSM

1. Beaumont Grosse Pointe 2. Borgess Medical Center 3. Bronson Medical Center 4. Crittenton Hospital and Medical Center 5. Forest Health Medical Center 6. Gratiot Medical Center 7. Harper University Hospital 8. Henry Ford Macomb Hospital 9. Henry Ford Hospital 10. Henry Ford Wyandotte 11. Hurley Medical Center 12. Lakeland Community Hospital 13. Marquette General Hospital 14. McLaren Regional Medical Center 15. Mercy General Health Partners 16. Metro Health in Wyoming 17. Munson Medical Center 18. Oakwood Hospital 19. Port Huron Hospital 20. Sparrow Health System 21. Spectrum Health System 22. St. John Hospital and Medical Center 23. St. John Oakland 24. St. Mary Mercy Hospital 25. St. Mary's Grand Rapids 26. University of MI Health System 27. Beaumont Troy 28. Beaumont Royal Oak 29. Huron Valley Sinai 30. Henry Ford West Bloomfield 31. St. Joseph Mercy Oakland 32. North Ottawa Community Hospital

Types of Data Collected by the MBSC Component Data Sources/Timing Content

Peri-operative care and outcomes

Chart review for all patients at 30 days post-op

Risk factors, treatment details, complications

Late outcomes Survey at baseline and mailed annually to all consenting patients

Late complications, weight loss, comorbidity

resolution, quality of life

Structure and process of care

Annual survey of surgeons and other bariatric

program staff

Specifics of bariatric practice, OR environment,

patient safety culture

Technical quality Videotaped operative procedures

Peer skill ratings

Subjective aspects of quality

Site visit Observed structure and process specifics

Cost BCBSM claims Payments for facility, professional, ancillary care

Collaborative quality improvement

• Robust, externally audited clinical registry • Rigorous, timely feedback to clinicians about

comparative performance • Identifying and implementing best practices

– Surgeons learning from their data – Surgeons learning from each other

• Quarterly meetings • Site visits • Watching videos

Measuring technical quality

• Surgeons submitted videotape of “typical” laparoscopic gastric bypass video

• Blinded peer rating • Technical skill rated according to modified

OSATS instrument

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Average Rating

Note: ◊ represents the mean; bars extend from mean ± standard error.

Average of Six Ratings of Technical Skill

Video # =

N Raters =

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Average Surgeon Rating

P-value for slope = 0.020

Average Rating vs. Any Complication Lap-RYGB Procedures Only

Surgical Care and Outcomes Assessment Program

Seattle Spokane

Yakima

•

Wenatchee

Richland

Port Townsend

Sunnyside

Aberdeen Kirkland

Portland

Longview

Port Angeles

Mt Vernon

Tacoma

Olympia

• Learning system focused on process of care • Surveillance • Process control • Process learning • Outcome control • Evidence-based Interventions

• Impact behavior through: Policy Peer to peer networking Checklists Education and public health initiatives

Green = Hospital meets or exceeds the benchmark performance rate for the metric GRAY = Hospital at least meets the SCOAP average, but not the benchmark rate for metric Yellow = Hospital is not reaching the SCOAP average, or the benchmark rate for metric Red = Hospital is one standard deviation away from the SCOAP average

Performance Benchmarking

0%10%20%30%40%50%60%70%80%90%

100%

2005 2006 2007 2008 2009 2010 2011

Leak Testing in Colon Surgery

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

$22,000

2006 2007 2008 2009

Non-SCOAP SCOAP

Bending the Cost Curve

Kwon et al. SCOAP at 5 years. Surgery 2012

Seattle

Spokane

Yakima

•

Wenatchee

Richland

Port Townsend

Sunnyside

Aberdeen Kirkland

Portland

Longview

Port Angeles

Mt Vernon

Tacoma

Olympia

Growing a “Real World” Learning System

• Spread across the interventional space Spine, urology, general/pediatric surgery, vascular Cross disciplines Target conditions-not procedures

• Post-hospital care • Pre-hospital space • Include patients NOT having interventions • Focus on metrics that matter

Had a spine fusion procedure

X-ray looks great….She doesn’t feel better

In a learning system….

Deborah becomes a partner in assessing care

Starting in docs office

oContact preference card

oBaseline function, QoL

oSurveyed at 6,12, 24 months

Capturing the Patient’s Voice

CERTAIN Hub Improving PRO data collection and patient survey experience

Patients are introduced to CERTAIN and asked to complete a PRO survey for neck or back pain

Evidence generation CER/PCOR

Partners in QI and

Research

Evidence into Practice

Patient Voices

Clinician Offices

Long-term Care

Hospitals

Surgery February 2012

Learning System Targets

• Topics emerge from the community • Perform statewide CER/PCOR to; Generate new evidence Evaluate if research applies to real world

• Evidence is evaluated, synthesized and “translated” into practice support

Do we all need to switch to Chloraprep?

849 gen surg pts 41% lower risk

CHG+IPA vs. PVI

Observed-to-Expected Ratio SSI: All Cases-n=11,000

0.4

1

1.6

CHG CHG+IPA PVI IPC+IPA Non-IPA IPA

Journal of the American College of Surgeons Volume 218, Issue 3, March 2014, Pages 336–344

The hospital changed our pain regimen and we noticed that we started to have leaks again-what’s up with that?

NSAID safety

Background

• NSAIDs being used more post-op • Do they impair GI healing? Schlacta et al. in study of post-operative pain

regimens showed 4x increased anastomotic leak in NSAID arm (p=0.15) o4 other small studies show elevated risk

• Assess the relationship between NSAIDs and anastomotic complications

Results

• SCOAP linked to CHARS 47 hospitals, 4 years, 13k+ patients undergoing GI

surgery involving an anastomosis RED FLAG for our community-education campaign

and decision support Opportunities for further research

Do we really need to use oral contrast?

Radiology-Pathology Concordance by Contrast Regimen

CT Scan Concordance 90.6%

No Contrast (n = 997) 85.7%*

IV Contrast Only (n = 4177)

90.4%

IV + enteral Contrast

(n = 2201) 90.0%

Enteral Contrast Only (n = 339)

92.6%

Should our surgeons be coming in to the hospital in the middle of the night?

Percent Perforation, by Deciles of ED to OR Time

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Perforation by Time of ED Presentation

Percent Perforation

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Perforation by Time of ED Presentation

Percent Perforation < median ED-OR time > median ED-OR time

DAYTIME HOURS NIGHTTIME HOURS

Collaboratives and Learning System

• Focus on real world-not just unusual care environments

• Put all elements together Doctors drive it-don’t become “victims” of it Patients become partners-outcomes that matter Data spans continuum of care Data from diverse sources All stakeholders at the table

Take Home Points-

• Collaboratives-effective tools for creating change and learning

• Learning system goal-Experiences of prior patients enrich the experience of all

• Surveillance is not enough-change is the goal